Nokea
The nurse is caring for a client diagnosed with deep vein thrombosis (DVT). Which intervention should the nurse include in the client's plan of care to prevent the complication of pulmonary embolism?
- A. Encourage ambulation as tolerated.
- B. Administer anticoagulants as prescribed.
- C. Apply cold compresses to the affected area.
- D. Encourage the use of incentive spirometry.
Correct Answer: B
Rationale: Administering anticoagulants as prescribed is crucial in preventing the complication of pulmonary embolism in clients with deep vein thrombosis. Anticoagulants help prevent the formation of new clots and the enlargement of existing ones, thereby reducing the risk of a pulmonary embolism. Encouraging ambulation as tolerated is beneficial for preventing complications related to immobility, but it is not the primary intervention to prevent pulmonary embolism in this case. Applying cold compresses to the affected area may help with pain and swelling but does not address the prevention of pulmonary embolism. Encouraging the use of incentive spirometry is more relevant in preventing respiratory complications such as atelectasis, not specifically pulmonary embolism.
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Prior to a cardiac catheterization, what instruction should the client be reminded of?
- A. You will need to be NPO for 6 to 8 hours before the procedure.
- B. You will not be able to move around during the procedure.
- C. You will be required to lie still for several hours after the test.
- D. You will not have to drink any fluids immediately before the test.
Correct Answer: A
Rationale: Being NPO (nothing by mouth) for 6 to 8 hours before a cardiac catheterization is crucial to prevent complications such as aspiration during the procedure. This helps ensure the safety and accuracy of the test results by minimizing the risk of food or liquid in the stomach interfering with the procedure. Choice B is incorrect because the client will need to lie still during the procedure to ensure its accuracy. Choice C is incorrect as the client is typically required to lie flat for a few hours after the test, not several hours. Choice D is incorrect as the client is usually not allowed to drink fluids immediately before the test to prevent complications.
The healthcare professional is reinforcing teaching for a client with peripheral artery disease (PAD). Which statement by the client indicates a need for further teaching?
- A. I will keep my legs elevated on pillows while resting.
- B. I will avoid crossing my legs when sitting.
- C. I will wear loose-fitting, comfortable shoes.
- D. I will avoid exposure to cold temperatures.
Correct Answer: A
Rationale: The correct answer is A. Elevating the legs can decrease blood flow in clients with PAD, worsening symptoms. Therefore, advising the client to keep the legs elevated on pillows while resting is incorrect and can exacerbate the condition. Choice B is correct as avoiding crossing legs helps prevent circulation restriction. Choice C is correct as wearing loose-fitting shoes promotes circulation. Choice D is correct as avoiding exposure to cold temperatures helps prevent vasoconstriction, which can worsen PAD symptoms.
A client with a diagnosis of heart failure is receiving digoxin (Lanoxin) and furosemide (Lasix). The LPN/LVN should closely monitor the client for which potential complication?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hypernatremia
- D. Hyponatremia
Correct Answer: B
Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that promotes the loss of potassium in the urine, potentially leading to hypokalemia. Hypokalemia increases the risk of digoxin toxicity, as digoxin's effects can be potentiated in the presence of low potassium levels. Monitoring for hypokalemia is crucial to prevent adverse effects and maintain the therapeutic effectiveness of digoxin in clients with heart failure. Choices A, C, and D are incorrect because furosemide does not typically cause hyperkalemia, hypernatremia, or hyponatremia. Instead, it commonly leads to hypokalemia due to increased potassium excretion.
A client with atrial fibrillation is receiving warfarin (Coumadin). The nurse should reinforce which instruction?
- A. Avoid foods high in vitamin K.
- B. Increase intake of dairy products.
- C. Limit intake of high-fiber foods.
- D. Avoid protein-rich foods.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in vitamin K. Clients taking warfarin need to be cautious with their vitamin K intake because vitamin K can counteract the effects of the medication. Therefore, it is essential to avoid foods high in vitamin K to maintain the therapeutic effects of warfarin. Choice B is incorrect because increasing dairy product intake is not specifically related to warfarin therapy. Choice C is incorrect as high-fiber foods do not interfere with warfarin therapy. Choice D is incorrect as protein-rich foods are not contraindicated with warfarin therapy.
A client with hypertension is prescribed a thiazide diuretic. What instruction should the nurse reinforce to the client?
- A. Take the medication in the morning.
- B. Increase potassium intake in the diet.
- C. Weigh yourself daily.
- D. Limit fluid intake to 2 liters per day.
Correct Answer: C
Rationale: The correct answer is to weigh oneself daily. This instruction is important as daily weights help monitor fluid loss and are crucial for detecting early signs of fluid imbalance when taking a diuretic. Weighing daily allows for timely adjustments in treatment and helps prevent complications associated with fluid imbalance. Choice A is not directly related to the client's need for monitoring fluid balance. Choice B, although important for some diuretics, is not specific to thiazide diuretics. Choice D is not appropriate as limiting fluid intake without proper monitoring can lead to dehydration, especially when taking diuretics.